My psych eval

This patient [select name="variable_1" value="is seen today for a psych evaluation and medication management. |is seen for ongoing medication management"]
This visit [select name="variable_1" value="is completed via telemedicine services delivered using HIPAA-compliant interactive video-audio telecommunication.|is conducted in the PACHS BH office."]
[checkbox name="variable_1" value="During the last visit the following changes were made:|This is the first visit with this provider for this patient."]
 is a -year-old, [checklist name="variable_1" value="White|Black|of mixed race|Asian|single|married|partnered|male|female."]
They present to this outpatient appointment [checklist name="variable_1" value="alone.|accompanied by their mother, .|accompanied by their father, .|accompanied by their significant other, .|accompanied by a friend."]. The patient appears to be a [checklist name="variable_1" value="reliable historian |unreliable historian."]  Information was obtained from the patient. [checklist name="variable_1" value="mother |father |significant other."]  Patient reports [checklist name="variable_1" value="a past history of | no history of mental health concerns.| no history of mental health concerns until ."] [checkbox name="variable_1" value="Depression|Anxiety|Sleep|Mood|PTSD|ADHD|Autism."]  They report experiencing [checklist name="variable_1" value="Deppressive symptoms of"][select name="variable_1" value="choice A|choice B|choice C"]

PAST PSYCHIATRIC HISTORY:
[checklist name="variable_1" value="Denies a past history of a psychiatric diagnosis.|Reports a past psychiatric diagnosis history of:"]
 [comment memo="Text that will not show up in output"]
[checklist name="variable_1" value="History of psychotherapy| No history of psychotherapy.| History of self harm includes:| No history of self harm attempts or acts| No history of past inpatient hospitalization| Has a history of being hospitalized inpatient: "]
[comment memo="Text that will not show up in output"]|There is no history of aggressive behaviors|There is a history of aggressive behaviors|There is a history of hallucinations:[comment memo="Text that will not show up in output"]|There is no history of hallucinations|Denies prior psychotropic medication trials|Reports prior psychotropic medication trials but unable to name medications|Reports past psychotropic medications as: [comment memo="Text that will not show up in output"]


MEDICAL HISTORY:
Primary Care Physician: [comment memo="Text that will not show up in output"]
Illness: [comment memo="Text that will not show up in output"]
Surgeries: [comment memo="Text that will not show up in output"]
Allergies:[comment memo="Text that will not show up in output"]
Head Injuries:[select name="variable_1" value="No history of head injury or traumatic brain injury|Reports a past history of traumatic brain injury from:"][comment memo="Text that will not show up in output"]
Seizures:[select name="variable_1" value="Denies having a history of seizures|Reports a history of seizures"]
DEVELOPMENTAL HISTORY:
[select name="variable_1" value="There is no known issue of meeting expected developmental milestones|All developmental milestones were met with the exception of:|There were some notable issues with developmental milestones including:"]
SOCIAL HISTORY:
was born in [comment memo="Text that will not show up in output"] to [checklist name="variable_1" value="an intact family|to a family structure consisting of [comment memo="Text that will not show up in output"]"]
Identifies [checklist name="variable_1" value="having no one|significant other|extended family|children|friends|church members"] as their social support network.
Level of education is [checklist name="variable_1" value="some high school|high school graduate|some college|college graduate"]
They have children. [select name="variable_1" value="They are currently employed|They are currently unemployed|They are currently on disability due to their mental health condition|They are currently on disability due to their medical condition"]. [checklist name="variable_1" value="At this time they have no legal concerns|At this time they have legal concerns including:"]